Ask the payment expert: How can I make sure that my Medicare claims are correct?

I recommend every facility that gets reimbursement from Medicare complete a Medicare audit annually. You want to look at yourself the same way the government does.

Have a random sample of 50 claims reviewed. If your error rate is below 5%, then you are probably doing well. Correct any issues identified and wait until next year.

However, if the error rate is above 5%, you probably want to expand that sample to a statistically valid sample, contact your attorney and consider self-reporting to the government.

You don't want to wait for the government to find you have coding or billing issues. This self-audit also can be a part of your QAPI program.

For more information about the OIGs expectation for self reporting, review the 2000 Corporate Compliance Guidelines for Nursing Facilities which can be found at https://oig.hhs.gov/authorities/docs/cpgnf.pdf and the 2008 update, which can be found at https://oig.hhs.gov/compliance/compliance-guidance/docs/complianceguidance/nhg_fr.pdf.

Another document that you may want to review is the recent OIG report called “Inappropriate Payments to Skilled Nursing Facilities Cost Medicare More Than a Billion Dollars in 2009” (OIE-02-09-00200). This report recommends the Centers for Medicare & Medicaid Services scrutinize SNF payments. Specifically, they recommended CMS: increase and expand reviews of SNF claims; use its Fraud Prevention System to identify SNFs that are billing for higher paying RUGs; monitor compliance with new therapy assessments; change the current method for determining how much therapy is needed to ensure appropriate payments; improve the accuracy of MDS items; and follow up on the SNFs that billed in error.

About 60,000 elderly or disabled Medicaid recipients in Louisiana are being told they should expect to lose their benefits in July, and advocates say more than a quarter of them could be forced out of the long-term care facilities they call home.